NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.

NO:1063024

CARDIOVASCULAR SYSTEM EXAMINATION

INSPECTION:1) JVP:- Jugular venous pressure
JVP is the reflection of phasic pressure changes in the right atrium and consists
of three positive waves (a,c,v) and three negative waves (x,y)
Visualisation of JVP:- The patient is positioned under 45, and the filling level of
the jugular vein determined. Visualize the internal jugular vein when looking for the
pulsation. In healthy people, the filling level of the jugular vein should be less than
3 centimetres vertical height above the sternal angle. A pen-light can aid in discerning
the jugular filling level by providing tangential light.
The JVP is easiest to observe if one looks along the surface of the sternocleidomastoid
muscle, as it is easier to appreciate the movement relative to the neck when looking
from the side (as opposed to looking at the surface at a 90 degree angle).
Differentiation from the carotid pulse
The JVP and carotid pulse can be differentiated several ways:

multiphasic - the JVP "beats" twice (in quick succession) in the cardiac cycle. In
other words, there are two waves in the JVP for each contraction-relaxation cycle by
the heart. The first beat represents that atrial contraction (termed a) and second beat
represents venous filling of the right atrium against a closed tricuspid valve
(termed v) and not the commonly mistaken 'ventricular contraction'.

non-palpable - the JVP cannot be palpated. If one feels a pulse in the neck, it is
generally the common carotid artery.

occludable - the JVP can be stopped by occluding the internal jugular vein by
lightly pressing against the neck. It will fill from above.

varies with posture and abdominal compression- the JVP varies with the angle
of neck.

varies with respiration - the JVP usually decreases with deep inspiration
JVP WAVEFORM

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

The " a " wave corresponds to right Atrial contraction. The peak of the 'a' wave
demarcates the end of atrial systole.

The " c " wave corresponds to right ventricular Contraction causing the
triCuspid valve to bulge towards the right atrium.

The " x " descent follows the 'a' wave and corresponds to atrial relaXation and
rapid atrial filling due to low pressure.

The " x' " (x prime) descent follows the 'c' wave and occurs as a result of the
right ventricle pulling the tricuspid valve downward during ventricular systole.

The " v " wave corresponds to Venous filling when the tricuspid valve is closed

The " y " descent corresponds to the rapid emptYing of the atrium into the
ventricle following the opening of the tricuspid valve.

The paradoxical increase of the JVP with inspiration (instead of the expected decrease)
is referred to as the Kussmaul sign, and indicates impaired filling of the right ventricle.

Large 'a' wave (increased atrial contraction pressure)

tricuspid stenosis

Right heart failure

Pulmonary hypertension

Cannon 'a' wave (atria contracting against closed tricuspid valve)

Atrial flutter

third degree heart block

Ventricular ectopics

Ventricular tachycardia

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

Absent 'a' wave

atrial fibrillation
Large 'v' wave (c-v wave)

Tricuspid regurgitation
Slow 'y' descent

Tricuspid stenosis

Absent y descent- in cardiac tamponade.

Prominent & Deep 'y' descent

Constrictive pericarditis
Parodoxical JVP (Kussmaul's sign: JVP rises with inspiration, drops with

expiration)

Pericardial effusion

Constrictive pericarditis

Pericardial tamponade

2)PRECORDIUM :- bulge or flattened

PRECORDIUM is the anterior aspect of the chest which overlies the heart. Normally
the precordium has a smooth contour, slightly convex and symmetrical with part of the
chest wall on the right side.
a)bulging:- seen in

enlarged heart
pericardial effusion
mediastinal tumor
pleural effusion
scoliosis

b)flattened: fibrosis of lung

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

congenital deformity
3)APICAL IMPULSE:- it is the lowermost and outermost part of cardiac impulse seen.
Normally it is in the left ICS just inside the midclavicular line. The impulse may not be
visible if it is lying just behind the rib,it may be visible in anterior axillary line in left
lateral position. It may not be visible in cases with emphysema or pericardial effusion.
4)PULSATIONS:a)juxta apical:- seen in ventricular aneurysms
b)left parasternal: right ventricular enlargement
left atrial enlargement
aneurysm of the aorta
c)epigastric:

right ventricular hypertrophy

aneurysm of aorta
liver pulsations
mass over aorta

d)in the 2nd left ICS:

dilated pulmonary artery

aneurysm of aorta
hyperkinetic state
enlarged left atrium

e)suprastrenal pulsations:

aortic regurgitation
coarctation of aorta
hyperkinetic state
abnormal thyroidema artery
pulsating thyroid gland

e) on the right side of the chest

dextrocardia
right atrial enlargement
g)at the back: Suzzmans sign in coarctation of aorta
Pulmonary A-V fistula
h)in the neck:-

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

hyperkinetic state
aortic regurgitation
carotid aneurysm
subclavian artery aneurysm

5)DILATED VEINS OVER THE CHEST WALL:- seen in

1)intrathoracic obstruction
2)superior venacava obstruction
3)right sided heart failure
6) SKIN OVER THE CHEST:a)skin eruptions- herpes infection
b)nodules- erythema nodosum seen in sarcoidosis, tuberculosis connective tissue
disorders,post streptococcal infection,drugs, inflammatory, metastatic, lipoma,
neurofibroma.
c)subcutaneous emphysema-air or gas is trapped in the subcutaneous layer. Causeso
o
o
o
o
o

1)chest trauma
2)tension pnuemothorax
3)pneumomediastinum
4)barotrauma
5)chest surgeries pnuemonectomy, thoracotomy
6)necrotising infections- fourniers gangrene it is a hallmark

d)purpuric spots,vascular spiders and bruisesNonthrombocytopenic purpuras may be due to:

Amyloidosis

Blood clotting disorders

Drugs that affect platelet function

Fragile blood vessels seen in older people (senile purpura)

Hemangioma

Inflammation of the blood vessels (vasculitis), such as Henoch-Schonlein

purpura, which causes a raised type of purpura

Pressure changes that occur during vaginal childbirth

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

Steroid use

Scurvy

Thrombocytopenic purpura
e)Scars of previous cardiac surgeries may be present and sinuses may be present in past
tuberculosis of spine.
PULSATIONS (see above)
1)LEFT PARASTERNAL
2)EPIGASTRIC
3)IN THE 2ND LEFT INTERCOSTAL SPACE
4)SUPRASTERNAL
5)ON THE RIGHT SIDE OF THE CHEST
6)AT THE BACK
7)IN THE NECK

PALPATION
1)LOCAL RISE OF TEMPERATURE:- warmth indicative of the toxicity and
septicemic conditions, empyema thoracis,chest wall infections
2)TENDERNESS:- tenderness over the chest wall may be present in local injury,
myositis,,pyogenic abscess and empyema.
3)APICAL POSITION:- is the outermost and lower most point of definite cardiac
impulse with maximal perpendicular thrust to the palpating finger.
1)NORMAL:- felt in the left 5th ICS 1cm medial to the midclavicular line or 10 cms
from the lateral midsternal line in left 5th ICS.
Normal apical impulse confined to one ICS and has an area of about 2.5 cms
2)DOWNWARDS:- left ventricular failure/congestive heart failure
3)OUTWARDS:- left ventricular hypertrophy, right ventricular hyper trophy,any large
mediastinal tumors causing mediastinal shift.
In hyperdynamic apical impulse it is displaced outwards and downwards seen in volume
overload conditions like aortic regurgitation and mitral regurgitation.

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

In case of heaving apical impulse, it is displaced outwards seen in pressure overload
conditions (eccentric hypertrophy) seen in conditions like systemic hypertension and
aortic stenosis.
4)NATURE OF THE APEX:A)NORMAL:- palpable in left 5th ICS
Tapping apex beat is generally in normal position seen in mitral stenosis due to loud s1
B)FORCIBLE:-two types
Heaving apex will be displaced outwards,forcible and sustained seen in pressure
overload.
Hyperdynamic apex is forcible and ill sustained displaced outwards and downwards
seen in volume overload conditions.
5)THRILL:- thrills are palpable vibrations associated with heart murmurs. They are best
felt with the palm of the hand. It is intensified if the chest wall is thin, site of production
is near to the surface of the chest wall and the blood flow is rapid. Presence of a thrill is
a definite evidence of the presence of an organic disease of heart.
NO THRILL
SYSTOLIC:- seen in
AS
PS
MR
TR
ASD
VSD
PDA
DIASTOLIC:- diastolic thrills are seen in MS
TS
AR
CONTINUOUS THRILLS in
PDA
Rupture of sinus of valsalva aneurysm
AV communication
PERCUSSION
Percussion is mainly done to determine the cardiac borders/boundaries. The roots of the
great vessel produce a dull note at the base of the heart which is difficult to differentiate
from the cardiac dullness. However percussion is useful to detect -

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

pericardial effusion
aortic aneurysm

The lower border of the heart cannot be percussed because it cannot be differentiated
from liver dullness.
1)LEFT BORDER:-percussed in 4th and 5th ICS in midaxillary region and then medially
towards the left ,the resonant note of the lung becomes dull. Normally left border is
along the apex beat. If it is outside the apex beat suggests pericardial effusion.
2)UPPER BORDER:- percussed in the left 2nd and 3rd ICS in the parasternal line.
Normally resonant note in the 2nd space and dull in 3rd space. If there is dull note in the
2nd space it suggests

Pericardial effusion
Aneurysm of aorta
Pulmonary hypertension
Left atrial enlargement
Mediastinal mass

3)RIGHT BORDER:- percussed anteriorly in the midclavicular line on the right side
until liver dullness is percussed. Then the percussion is done one space higher from mid
clavicular line medially to the sternal border. Normally the right border of the heart is
retrosternal. If the dullness is parasternal it suggests

Pericardial effusion
Aneurysm of ascending aorta
Right atrial enlargement
Dextrocardia
Mediastinal mass
Right lung base pathology

AUSCULTATION
1)HEART SOUNDS:- normally there are four heart sounds recorded
phonocardiographically but clinically in majority of the cases only two heart sounds are
audible. The heart sounds auscultated in all four areas of the chest namely mitral,
tricuspid, pulmonary ,aortic areas.
The first heart sound is best appreciated in the mitral area and second in aortic and
pulmonary areas.
Normally the first heart sound is single because the tricuspid and mitral components
occur simultaneously.
The second heart sound is normally split,because the aortic valve closes earlier than the
pulmonary valve.this split can be best appreciated in the pulmonary area.

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

AREA

SITE

1)Mitral area

5th left ICS just inside the mid clavicular line

2)Tricuspid area

Lower end of sternum near the ensiform cartilage

3)aortic area

right 2nd intercostal area

4)pulmonary area

left 2nd intercostals area

5)Erbs area or

left 3rd intercostal area

Neoaortic area
6)Gibbsons area

left 1st ICS close to sternum, PDA murmur is best heard.

A)NORMAL
B)DECREASED :- heart sounds are decreased in pericardial effusion,cardiac
tamponade.
POOR conduction of sound through chest wall occurs in

Pericardial effusion
Emphysema
Thick chest wall
Obesity

C)INCREASED:- heart sounds are loud or increased in

1)sinus tachycardia
2)mitral stenosis
3)tricuspid stenosis
4)thyrotoxicosis
5)anemia
6)beriberi
7)A-V fistula
8)Left to right shunt:- PDA, ASD, VSD.

D)ADDITIONAL:- other sounds audible are murmurs, opening snap,pericardial rub,

pericardial knock , tumor plop.
2) S1 :- SOFT OR LOUD
It is produced by the closure of mitral and tricuspid valves(AtrioVentricular valves).
Normally the mitral valve closes before the tricuspid valve by 20-30 msec. Hence S1 is
appreciated as a single sound.

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

It is high frequency sound heard best with the diaphragm of the stethoscope.
It is timed with simultaneous palpation of the carotid pulse. S1 indicates the onset of
systole.
LOUD S1:Due to increased excursion of the AV valve leaflets from each other during opening,
there is a loud sound when they close.
a)normal in children
b)sinus tachycardia
c)prolonged a-v filling due to a-v stenosis example:- MS ,TS
d)increased a-v flow from high cardiac output ex:thyroyoxicosis,anemia,beriberi,A-V fistula
e)increased A-V flowfrom left to right shunt ex:-PDA, ASD,VSD.
f)short P-R interval

SOFT S1:a)poor conduction of sound through chest wall:

pericardial effusion
emphysema
thick chest wall
obesity

b)rigidity and clacification of AV valve ex:- MS with calcified valves

c)mitral regurgitation and tricuspid regurgitation
d)prolonged P-R interval
e)acute MI, LV aneurysm, cardiomyopathy
VARIABLE S1: a)atrial fibrillation
b)complete heart block
c)A.V.dissociation
Causes of splitting of S1:

a)RBBB with pulmonary hypertension

b)Left ventricular pacing
c)Ecopic beats and idioventricular rhythms from LV
d)Ebsteins anomaly

Causes of reverse splitting of S1:-

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

a)right ventricular pacing
b)ectopic beats and idioventricular rhythms from AV
2)S2:- SPLIT/ WIDELY SPLIT/ REVERSE SPLIT/ SINGLE SECOND SOUND
S2 is produced by closure of the aortic (A2) and pulmonary(P2) valves.
It is normally split because the aortic valve closes before the pulmonary valve. The A2
is normally louder than P2. During inspiration, the splitting of A2P2 becomes wider.
During expiration the splitting is narrower and S2 may be haerd as a single sound,.
ABNORMAL SPLITTING OF S2:A)WIDELY SPLIT S2:1)Electrical : RBBB,
left VPB,
LV pacing
2)mechanical:

ASD
VSD
pulmonary failure
RV Failure(acute pulmonary embolism)
severe MR

B)REVERSE SPLITTING OF S2:- it occurs due to early closure of p2 or delayed

closure of a2
Early P2- WPW syndrome(type b)
Delayed A2

Aortic stenosis
Hypertrophic cardiomyopathy
Large PDA
Left BBB
Right ventricular pacemaker
Right ventricular ectopics
Systemic hypertension

S2 in eisenmenger syndrome
VSD-single loud S2
PDA-close split S2

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

ASD- narrow fied split S2
C) SINGLE S2:a)diminished intensity of A2 or P2:- AS ,PS,pulmonary atresia, tetrology of fallot.
b)P2 synchronous with A2:-VSD ,single ventricle
c)concealed by systolic murmur/continuous murmur
4) S3 AND S4:S3:- S3 occurs in early diastole, when the ventricle is dilated and noncompliant. It
occurs during passive diastolic ventricular filling and usually indicates serious
ventricular dysfunction in adults; in children, it can be normal, sometimes persisting
even to age 40. S3 also may be normal during pregnancy.RV S3 is heard best (sometimes
only) during inspiration (because negative intrathoracic pressure augments RV filling
volume) with the patient supine. LV S3 is best heard during expiration (because the heart
is nearer the chest wall) with the patient in the left lateral decubitus position. It is also
heard in: MR,TR,
CCF MI,
ASD,VSD,PDA
high output states
dilated cardiomyopathy
S4:-it is low frequency sound. It occurs due to rapid emptying of atrium into non
compliant ventricle in rapid filling phase due to atrial contraction, heard best with the
bell of a stethoscope. Normally it is inaudible
Elderly>60yrs
MI, LV Failure(S1+S2+S3/S4= GALLOP )
AS,HOCM
PS, pulmonary hypertension
5)ADVENTITIOUS SOUNDS
A)PRESENT B)ABSENT

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

IF PRESENT:A)CLICKS:-they are produced due to the opening of semilunar valves. They are high
pitched,click-like sounds that come after S1 and best heard in aortic or pulmonary areas.
1)pulmonary ejection click:- best heard in expiration.Causes dilatation of pulmonary artery
PS
pulmonary hypertension
2)aortic ejection click:- transmitted to the apical area. Causes

Aortic aneurysm
AR
AS
Coarctation of aorta
Hypertension

3)mid systolic ejection click/non ejection click:- produced by prolapsed if AV valve

leading to tensing of chordae tendinae. Causes mitral,tricuspid valve prolapse
B)OS:-opening snap is high pitched loud snapping sharp sound due to sudden tensing of
the cusps of mitral valve as it tries to open during early diastole,accentuated with
exercise and best heard with diaphragm of stethoscope.
OS may be soft or absent in MS when there is : Mild MS
Calcific mitral valve
Mitral stenosis with associated MR
C)PERICARDIAL RUB:-this is caused by slashing movements imparted by the
heartbeat to exudates within the pericardial sac. It is creaky,rasping synchronous with
the heart beat and not transmitted. Heard in

Viral pericarditis,Pyogenic pericarditis,Tuberculous pericarditis

Acute MI
Acute RF
Uremia
Dresslers syndrome

INNOCENT MURMURS:-soft systolic murmurs heard in patients without any cardiac

abnormality,commonly heard in children usually not loud murmur ,no thrills soft and
blowing in nature usually systolic may be continuous.
SYSTOLIC MURMURS:-occur between S1 and S2,types1)mid systolic or ejection systolic mumurs-

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

Aortic AS, HOCM,carctation of aorta, PDA,AR,aneurysm
Pulmonary-PS,ASD,VSD,fallots tetrology and high otput state
2)late systolic murmurs- mitral valve prolapsed(MVP),TVP,HOCM,papillary muscle
dysfunction.
3)pansystolic- MR, TR, VSD
4)early systolic murmurs- acute severe MR, TR and very small VSD or largeVSD with
pulmonary hypertension.
DIASTOLIC MURMURS:-occur between S2 and S1(diastole). types1)early diastolic:- AR, PR and Graham Steels murmur(pulmonary area best heard)
2)mid-diastolic:

MS, TS,
Carey Coombs murmur
Austin flint murmur
Flow murmurs- as in ASD,VSD,PDA ,MR, TR,complete heart block(Rytands
murmur)

3)late diastolic:- or presystolic murmurs heard in:

MS
TS
Left atrial myxoma
Right atrial myxoma

CONTINUOUS MURMURS:- A continuous murmur is one which begins in systole,

continues through S2 into part or whole of diastole. Heard in

PDA
Aortoplmonary window
Tricuspid and pulmonary atresia
Coarctation of aorta
AS with AR and VSD with AR
Venous hum
Mammary souffl

VENOUS HUM:- low pitched soft continuous murmur heard in children commonly and
accentuated by exercise
MAMMARY SOUFFLE:-best heard over mammary area and 2nd ICS during pregnancy
and postpartum.

Heart Murmur Intensity

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

Grade Description
1

Barely audible

Soft but easily heard

Loud without a thrill

Loud with a thrill

Loud with minimal contact between stethoscope and chest

Loud with no contact between stethoscope and chest

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024

NAME: C.L.S.SOWJANYA ROLL.NO:23 UNIVERSITY REG.NO:1063024